Clinical Population Management (CPM)

​The simplest way to optimize​chronic disease care.

Save time.

Reduce costs.

Improve results.

WE'RE ENTERING A NEW ERA in healthcare, one that rewards providers based on the efficiency and quality of their care, not simply the quantity. And the focus is no longer centered solely around individual care; providers are increasingly held accountable for the value of care provided across their entire patient panel, including patients who don't take initiative with their medical needs. This means we need to know what's going on with all patients, not just those who've had a recent office visit. And we need to be able to demonstrate population outcomes in addition to individual outcomes.

In the field of chronic disease care, we desperately need to change our systems of care to address these changing expectations and create a comprehensive, sustainable, value-based care model. But how? The answer is Clinical Population Management (CPM).

Leverage your data.What we're offering on this site is an open-access approach to implementing CPM. Any and all practices are invited to freely use it as a framework for providing far more efficient, effective chronic disease care. CPM enables physicians and their practice teams to build and leverage the wealth of population data at their disposal and use it to deliver the best possible care to every patient in their practice.

See your entire patient population.Traditional chronic disease care focuses on the needs of individual patients at the time of their office visit, and for the most part only during this visit. CPM allows you to also see that patient within the context of your practice's entire patient population. This capability enables your practice team to track the care of all patients in real time, ensure on-time disease assessments across your patient population, and tailor care protocols based on patients' disease activity levels, disease duration, and prognosis.

Maximize your value.Such information-driven care also enables practices and health systems to coordinate the management of patients with multiple chronic diseases and provides an opportunity for chronic disease specialists to expand their understanding of specific diseases and treatments. In short, CPM is a tested pathway to providing the best possible care for patients, both individually and across the chronic disease spectrum.

How It Works

OUR APPROACH TO Clinical Population Management is an outgrowth of pioneering efforts by clinicians in the RAPP Project, an innovative chronic disease care quality improvement initiative. Comprehensive instructions for implementing CPM are provided in a Step-by-Step Guide, but here's a quick summary of how it works:

Step one is to consistently document patient disease activity data (and medication and other treatment data, if desired). Our simple data collection process can be accomplished in less than 20 seconds during a patient visit.

Step two is to add the data collected during each patient visit to a population registry database. You can select any population registry; just be sure it includes these features.

Step three involves analyzing your population data. A population registry can be used to stratify patients by their disease activity levels, disease duration, and prognosis. This enables the care team to differentiate interventions for each segment of the disease population based on recommended care.

Step four is about improving care and workflows. CPM enables high-quality, team-based care. The ability to "see" your entire patient panel will allow you to better align processes and resources to meet the needs of each patient and subsequently improve outcomes..